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Soft-Tissue Management and Neurovascular Protection During Opening-Wedge High Tibial Osteotomy
Kristian Kley, Hamid Bin Abd Razak, Raghbir Khakha, Adrian Wilson, Ronald van Heerwaarden, Matthieu Ollivier
To cite this version:
Kristian Kley, Hamid Bin Abd Razak, Raghbir Khakha, Adrian Wilson, Ronald van Heerwaarden, et al.. Soft-Tissue Management and Neurovascular Protection During Opening-Wedge High Tibial Osteotomy. Arthroscopy Techniques, Elsevier, 2021, 10, pp.e419 - e422. �10.1016/j.eats.2020.10.020�.
�hal-03245875�
Soft-Tissue Management and Neurovascular Protection During Opening-Wedge
High Tibial Osteotomy
Kristian Kley, M.D.,
Hamid Rahmatullah Bin Abd Razak, M.B.B.S., F.R.C.S.Ed. (Orth), F.A.M.S., Raghbir S. Khakha, M.B.B.S., B.Sc., M.Sc., M.R.C.S., F.R.C.S.,
Adrian J. Wilson, M.B.B.S., B.Sc., F.R.C.S. (Tr&Orth),
Ronald van Heerwaarden, M.D., Ph.D., and Matthieu Ollivier, M.D., Ph.D.
Abstract: Medial opening-wedge high tibial osteotomy (OW-HTO) is an excellent surgical option for patients with varus knee osteoarthritis. Medial collateral ligament (MCL) release and posterior neurovascular structure protection during OW- HTO are steps that often induce stress and nervousness during surgery, especially for surgeons in the earlier stages of their learning curve. While is it well-known that the MCL should be released during OW-HTO, the standard retraction tech- niques pose challenges in visualization and instrument placement in the surgical field. We present our technique, which illustrates an alternative method to manage the MCL and safely protect the neurovascular structures using a second and more posterior surgical window during OW-HTO.
T he medial opening-wedge high tibial osteotomy (OW-HTO) is a robust surgical option for treatment of medial compartment osteoarthritis with varus malalignment.1 Despite good outcomes, complication rates following OW-HTO have been consistently re- ported to be around 30%.
2 Although rare (1.7%), neurovascular injury following OW-HTO is devastating when it occurs.
2 To prevent neurovascular injury, several techniques have been previously described, including the use of a protective cutting system,
3
patient-specific cutting guides,
4 and computer-assisted navigation.
5 There has been much discussion about the management of the medial collateral ligament
(MCL) following OW-HTO.
6,7It is well-known that the MCL has to be released in OW-HTO.
6In a standard approach for OW-HTO, the MCL is raised sub- periosteally to the posteromedial tibia before a large retractor is placed behind the tibia to protect the neu- rovascular structures (NVS). However, the surgical as- sistant often has to fight against the resistance of the intact MCL, and this poses challenges in visualization and instrument placement in the surgical field. The purpose of this article is to present, in detail, a tech- nique to manage the MCL and safely protect the NVS using a second and more posterior surgical window during OW-HTO.
From London Osteotomy Centre, Harley Street Specialist Hospital, London, United Kingdom (K.K., H.R.B.A.R., R.S.K., A.J.W., R.v.H.); Orthoprofis, Hannover, Germany (K.K.); SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme, Singapore (H.R.B.A.R.); Department of Or- thopaedic Surgery, Sengkang General Hospital, Singapore (H.R.B.A.R.);
Department of Orthopedics and Traumatology, St. Marguerite Hospital, Aix Marseille Univ, APHM, CNRS, ISM, Institute of Movement and Locomotion, Marseille, France (M.O.); Department of Orthopaedics, Guys & St Thomas’s Hospital, London, United Kingdom (R.S.K.); Department of Sports and Ex- ercise, University of Winchester, Winchester, United Kingdom (A.J.W.); and Centre for Deformity Correction and Joint Preserving Surgery, Kliniek Via- Sana, Mill, The Netherlands (R.v.H).
The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, assupplementary material.
Received August 16, 2020; accepted October 17, 2020.
Address correspondence to Dr. Matthieu Ollivier, M.D., Ph.D., Department of Orthopedics and Traumatology, St. Marguerite Hospital, Aix Marseille Univ, APHM, CNRS, ISM, Institute of Movement and Locomotion, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France. E-mail:
Ó2020 by the Arthroscopy Association of North America. Published by Elsevier. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
2212-6287/201414
https://doi.org/10.1016/j.eats.2020.10.020
Arthroscopy Techniques, Vol 10, No 2 (February), 2021: pp e419-e422
e419
Surgical Technique (With Video Illustration)
Positioning and Draping
After induction of general or spinal anesthesia, the patient is positioned supine. The use of a pneumatic tourniquet is based on surgeon’s preference. The leg is prepared and draped in a sterile fashion.
Diagnostic Arthroscopy
A diagnostic arthroscopy is performed to confirm medial compartment disease and exclude significant chondral lesions in the lateral and patellofemoral compartments.
Surgical Procedure
The surgical procedure is presented in Video 1. To summarize, the knee is positioned in a fl exed position.
A medial approach to the proximal tibia is performed with an oblique skin incision running from the post- erosuperior to anteroinferior aspect, starting 2 cm
below the tibiofemoral joint line and extending 5 to 6 cm toward the distal tibia (Fig 1). The edge of the patellar tendon is then bluntly dissected and marked in preparation for the biplane osteotomy cut along the tibial tubercle. A subcutaneous soft-tissue dissection exposes the pes anserinus. The pes anserinus is dissected by inserting and spreading the jaws of an Overholt clamp (Fig 2). After its posterior retraction, the vertical fibers of the MCL are easily identified.
Instead of retracting the MCL and placing a posterior retractor from its anterior border, we create a second soft-tissue window at the posterior border of the MCL (Fig 3). Starting at the posterior border of the MCL, a periosteal elevator is used to dissect the soft tissue until the posterior cortex of the tibia is reached and the popliteus muscle carefully released (Fig 4). This elevator is then left in place to guide the posterior tissue retractor (Newclip Technics, Nantes, France) between the posterior cortex and popliteus muscle (Fig 5).
Fig 1. Anatomical landmarks to determine skin incision.
Fig 2. An Overholt clamp is placed underneath the ham- strings and the jaws are opened to release them.
Fig 3. Demonstration of a window being created posterior to the super fi cial MCL to allow access to the posterior cortex.
(MCL, medial collateral ligament.)
Fig 4. A periosteal elevator is run along the posterior tibial cortex to create a safe passage for the neurovascular protector.
(MCL, medial collateral ligament.)
e420 K. KLEY ET AL.
This step can be done with the knee in flexion to facilitate insertion. After the posterior tissue retractor (PTR) has been inserted, the periosteal elevator is removed progressively and is used as a “feeler” to palpate the posterior aspect of the tibia and with 180
twists, used to confirm that there is no intervening soft tissue trapped between the posterior aspect of the tibia and the PTR. The deep MCL and proximal tibial attachment of the MCL remain attached. The distal part of the super fi cial MCL is then released and a small Hohmann retractor is used to retract it, presenting the medial proximal tibial surface for the osteotomy (Fig 3).
Following the saw cuts for the osteotomy under fluo- roscopic control, a metal ruler or a chisel is used to palpate the PTR through the osteotomy gap to confirm that the posterior tibial cortex has been completely osteotomized. The wedge opening is then performed by
placing a spreader device, posterior to the MCL along the cut posterior cortex. The MCL tension can be assessed and a pie-crusting technique can be used for further fine-tuning. Usually, a small release of the posterior fibers of the MCL allows sufficient length- ening, while maintaining the integrity of the superficial MCL (Fig 6). The rest of the procedure can be under- taken in standard fashion.
Postoperative Protocol
Patients are allowed to weight bear fully if tolerated, with full range of motion and if needed, with the aid of crutches. Chemoprophylaxis against venous thrombo- embolism is prescribed for 3 weeks.
Discussion
The OW-HTO is an excellent option for younger pa- tients with varus osteoarthritis, given that outcomes following total knee arthroplasty in this patient group are poor.
8,9While OW-HTO has been gaining popu- larity in recent years, it has been shown that the learning curve for OW-HTO ranges from 27 to 42 procedures.
10Despite good outcomes, complication rates following OW-HTO have been consistently re- ported to be around 30%.
2We believe that our described technique can reduce the complications of tibial plateau fractures as well as neurovascular injuries.
Tibial plateau fractures following OW-HTO has an incidence that ranges from about 1% to 11%.
11This usually occurs from an incomplete osteotomy. With our technique, we can confirm that there is no intervening soft tissue between the PTR and the posterior cortex of the tibia. The surgeon can then confidently complete the planned osteotomy cut, leaving the lateral hinge intact. This should reduce the risk of tibial plateau fractures.
Fig 6. Anatomical representation of the posterior tissue retractor protecting the neurovascular structures and a mini- Hohmann presenting the medial aspect of the tibia for osteotomy.
Fig 5. Graphical and anatomical representation of the posterior aspect of the knee showing the neurovascular bundle and
popliteus muscle. The green highlighted area shows the position of the posterior tissue retractor (PTR). (MCL, medial collateral
ligament.)
According to the literature, there are anatomical variants in the division of the popliteal artery. An aberrant high branching of the anterior tibial artery running posterior to the popliteus muscle has been previously reported.
12,13Therefore, placement of the PTR after releasing of the popliteus off the posterior aspect of the proximal tibia will offer excellent protec- tion of the NVS while the surgeon saws the posterior tibial cortex. Feedback of contact between the saw tip and the PTR confirms that the posterior cortex has been osteotomized. Although rare (1.7%), neurovascular injury following OW-HTO is devastating when it occurs.
2Besides offering complete protection of the NVS, positioning the posterior retractor through a second surgical window along the posterior border of the MCL allows us to perform a controlled and patient-specific release following opening of the osteotomy. We could potentially prevent both excessive pressure (from under-release) on the medial compartment and medial instability (from over-release). Our technique also has some disadvantages. A broad and sharp periosteal elevator is required to dissect the soft tissue until the posterior cortex of the tibia is reached and the popliteus muscle carefully released. Without the appropriate tool, there is danger of injuring the neurovascular structures.
The advantages and disadvantages of our technique are presented in Table 1.
To conclude, we are convinced that by creating a secondary window posterior to the MCL allows excellent protection of the posterior neurovascular structures, prevents collision of retractors and the power instruments, and allows us to perform a more controlled release of the MCL following the osteotomy.
References
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Table 1. Advantages and Disadvantages of the Second Window Approach
Advantages
Prevention of excessive tension on MCL
Excellent protection of posterior neurovascular structures Offers opportunity for more controlled release of MCL following
osteotomy Disadvantages
Potential injury to posterior neurovascular structures without appropriate instruments
MCL, medial collateral ligament.
